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EXECUTIVE SUMMARY
1. The following memorandum sets out evidence from the Department of Health to the House of Commons Health Committee about the credentials of overseas doctors.
2. Following the recent report into out of hours services by Dr David Colin-Thomé and Professor Steve Field, it is clear that there are already very robust requirements in place to ensure the commissioning and delivery of safe and high quality out-of-hours services. However, that there is some variation in how PCTs apply those requirements and controls.
3. In light of the report the Government announced a series of measures to tighten existing controls to ensure PCTs are meeting their legal obligations through commissioning and contracting arrangements and that providers are employing competent clinicians to practice as GPs in primary care out-of-hours.
4. There are three levels of checks on the credentials of doctors entering the United Kingdom seeking to work in out of hours services.
5. In addition to the specific measures which we have proposed to address the concerns which have been raised about a small minority of doctors working in GP out of hours services, there are a number of initiatives that the government is currently taking forward which will strengthen the systems in place for ensuring that all doctors are fit to practise.
6. These measures will further strengthen the existing framework for identifying and addressing concerns about doctors, in the small number of cases where they arise.
INTRODUCTION AND CONTEXT
1.1 The following memorandum sets out evidence from the Department of Health to the House of Commons Health Committee about the credentials of overseas doctors.
1.2 It is important to note that overseas doctors generally fall into one of two categories.
1.3 The Department's understanding is that the Committee is seeking evidence in light of the Coroner's Inquest into the death of Mr David Gray, following treatment by Dr Daniel Ubani. The memorandum therefore focuses primarily on the arrangements as they apply to doctors seeking to work in out of hours services and restricts itself to the arrangements in England.
1.4 The Committee will be aware that there
are complex arrangements with respect to devolution and the registration
and employment of doctors from overseas.
1.5 Policy on the role of the doctors' regulatory
body—the GMC—is reserved to Westminster and therefore
the arrangements for including doctors on the register of medical
practitioners apply across the United Kingdom, whereas policy
on the health service is devolved to Northern Ireland, Scotland
and Wales.
OUT OF HOURS GP SERVICES
Carson review
1.6 Before the introduction of the new General
Medical Services contract, GPs were responsible for the provision
of out-of-hours services for their own patients.
1.7 However this twenty four hour responsibility for out of hours care was unpopular with GPs who felt it was discriminatory and so, as part of the negotiations for the 2004 General Medical Services contract, which came into force on 1 January 2005, it was agreed to allow GPs the option to transfer their responsibility for out-of-hours services to PCTs. This was key to the acceptance of the contract by GPs.
1.8 The quality of care varied considerably between different provider types and different geographical areas, and in early 2000, a rising number of complaints and negative reports in the media led the Health Service Commissioner (Ombudsman) to raise concerns about out-of-hours services with the Department.
1.9 This evidence led the Department to
conclude that the existing model of out-of-hours was not sustainable.
1.10 As a result, in March 2000 the Department
announced an independent review of the arrangements for GP out-of-hours
services across England—the Carson review. The review was
led by Dr David Carson and his report—Raising Standards
for Patients New partnerships in out-of-hours Care[1]—was
published in October 2000.
1.11 All 22 recommendations were accepted and have been implemented including the introduction of a new integrated model of delivery, new national quality requirements and better use of health professionals and their skills in the delivery of out-of-hours care.
Introduction of current arrangements
1.12 The 2004 GMS contract allowed GP practices
to opt out of providing out of hours services and transfer the
responsibility for providing these services to PCTs. From 1 January
2005, GP practices were able do so as a right.
1.13 At the beginning of 2004, approximately
70% of GPs had delegated the responsibility to a GP co-operative,
and around 25% to a commercial provider.[2]
1.14 The vast majority of practices (90%)[3]
transferred their OOH responsibility to the PCT. Where PCTs assumed
responsibility for OOH services, they either provide OOH services
directly themselves, or commission services from provider organisations
1.15 The quality of Out of Hours care for most people is better than it was in 2004. A 2006 review of Out of Hours care by the National Audit Office[4] said, "England is at the forefront of thinking internationally" on Out of Hours care and that "England compares well on cost and quality against the rest of the UK".
1.16 A 2008 Healthcare Commission report on urgent and emergency care[5] also said that, "There have been significant improvements over recent years in the... number of out-of-hours GP services meeting national quality requirements". "These achievements have taken place despite the pressure from the significant growth in demand for many of these services". While these reports rightly indicate that quality improved following the 2004 changes, local implementation of the new arrangements has not always been perfect.
Current issues with GP OOH services
1.17 In June 2009, the Care Quality Commission (CQC) began an investigation into the provision of out-of-hours primary care services in five PCTs by Take Care Now (TCN). The CQC's enquiry was prompted by the tragic death of Mr Gray in February 2008 after he was administered 100mg of diamorphine by Dr Daniel Ubani, a locum doctor from Germany.
1.18 In October 2009, the CQC issued an interim statement on this investigation, which prompted Dr David Colin-Thomé, the Department of Health's National Clinical Director for Primary Care, to write to PCTs[6] reminding them of their legal responsibilities to provide safe, high quality out-of-hours care for their patients.
1.19 Concerns about out-of-hours care were raised with the Department last summer. These concerns coupled with the CQC investigation led Ministers to ask Dr David Colin-Thomé and Professor Steve Field, Chairman of Council, Royal College of General Practitioners, to jointly lead a review of the current arrangements for the local commissioning and provision of out-of-hours services.
1.20 The report,[7] published on Thursday 4 February, considered the commissioning and performance management of out-of-hours services, the selection, induction, training and use of out-of-hours clinicians, and the management and operation of PCT performers lists.
1.21 It is clear from this report that there are already very robust requirements in place to ensure the commissioning and delivery of safe and high quality out-of-hours services. The report's authors saw several examples of good practice from both commissioners and providers. However there is variation in how PCTs apply those requirements and controls. The report set out twenty-four recommendations which the Department accepted in full, insofar as they apply to the Department or the NHS. The recommendations included:
1.22 The Department also announced a further range of new measures to strengthen arrangements for the commissioning and provision of out of hours services:
1.23 The issues surrounding the report and the report of the Coroner's Inquest have raised concerns about the credentials of some doctors from outside the UK, particularly the employment and regulatory checks on EEA doctors and the use of EEA doctors in out-of-hours GP services.
DEPENDENCE ON OVERSEAS DOCTORS
1.24 For most of its history, the National Health Service has relied upon the contribution of doctors who trained outside Europe. The service has always been open to the exchange of experience and expertise that flows from operating within an increasingly global workforce.
1.25 Although medical practitioners who qualified outside the United Kingdom have probably been a feature of the NHS since its inception in the 1940s, it is clear that by the 1960s the NHS benefitted significantly from the contribution to it made by doctors of Indian and Pakistani origin.[8] In that decade there was an expansion in the capacity of the NHS and this was largely filled by recruitment of doctors from the Indian Subcontinent.
1.26 Throughout the 1970s there was a concern that domestic workforce supply would be insufficient to maintain existing staffing numbers[9],[10] and by the 1980s and 1990s numbers of overseas doctors increased substantially to fill a capacity gap created by NHS reforms, demographic change and various other factors.[11]
1.27 The number of doctors qualified outside of the European Economic Area increased gradually from 15,190 in 1992 to 20,737 in 2000.[12]
1.28 In 2000, the Government published the NHS Plan.[13] The demand for additional NHS staff in England in the short term was such that international recruitment had to be a key contributor in helping expand the workforce and this was explicitly recognised in the NHS Plan which stated:
NUMBERS OF OVERSEAS QUALIFIED MEDICAL STAFF IN GENERAL PRACTICE
1.29 The NHS Information Centre holds information relating to numbers of doctors in medical (non-dental) specialties within the hospital and community health services and general practitioners in the NHS in England by country of qualification. That is, the country in which they obtained their primary medical qualification, grouped into UK, EEA and Elsewhere.
1.30 In 2008 there were 34,010 practitioners in general practice in England[14] of these 26,648 (78%) qualified in the UK compared with 22,807 (81%) out of 28,251 in 1998.
1.31 Within the 22% of practitioners qualifying overseas in 2008, there was a modest increase in those qualifying in the rest of the EEA. Practitioners qualifying in the rest of the EEA rose from 884 (3%) in 1998 to 1,619 ( 5%) in 2008.
SELF-SUFFICIENCY
1.32 The NHS in England has been working
towards greater self-sufficiency by recruiting home-grown staff
and getting a more diverse workforce that reflects local communities
since the NHS Plan was published. However, the enormous
investment in extra training and improving retention that followed
the NHS Plan could not deliver immediate expansion.
1.33 Now however, due to the rapid levels
of workforce expansion in the NHS over the past nine years, a
steady state has been reached where, for most staff groups, the
supply of UK-trained staff more closely matches the demand for
healthcare services. Consequently, the emphasis on international
recruitment has fallen and the international recruitment programmes
funded by the Department of Health have now stopped.
1.34 The number of medical training places made available at undergraduate and postgraduate levels is based on the long-term forecast demand for trained doctors and Government policy to move towards self-sufficiency in the supply of trained doctors. Medical school intake in England almost doubled from 3,749 in 1997 to 6,477 in 2008.[15] This will enable us to move towards a greater degree of self-sufficiency in the future.
1.35 The aim is that the increase in UK supply will, over time, reduce reliance on international medical graduates to take up specialist training in order to meet the demand for trained specialists. Operational increases in numbers are not filled immediately with UK graduates because of the time lag. Training takes seven years so there may be a proportionate decline while the increased numbers of students progress through seven years' training.
1.36 International recruitment will continue to have a much smaller role as part of a comprehensive workforce strategy, with NHS employers co-ordinating their own activity.
1.37 The policy for greater self-sufficiency in the supply of healthcare professionals and less reliance on doctors and nurses from developing countries, requires a balancing policy for managing healthcare migration.
MOTIVATION OF OVERSEAS DOCTORS
1.38 There are a number of different reasons why doctors from overseas want to work in the UK:
Specialty Training.
1.39 Graduates of UK medical schools—Doctors
(regardless of nationality) who have completed full undergraduate
medical degree in the UK can go on to have permanent careers in
the NHS with the ability to compete for access to foundation programmes
and specialty training.
1.40 Where doctors from the EEA seek to
gain access to specialty training they compete in open competition
with UK nationals for foundation and specialty training programmes.
In practice though, very few EEA doctors who have trained in medical
schools outside the UK apply for UK foundation and specialty training
programmes.
1.41 There is far greater competition from
doctors who are not EEA nationals. The UK provides high quality
post-graduate and specialty training that is well regarded around
the world. Doctors in training in the NHS are paid whilst they
train—starting pay for doctors on specialty training programmes
is around £28,000 per annum. There are no fees charged to
doctors for post-graduate and specialty training programmes. This
makes the UK a very attractive destination for International Medical
Graduates who want to progress their careers, particularly if
their home country has limited opportunities for post-graduate
and specialty training.
MEDICAL TRAINING INITIATIVE.
1.42 On Friday 29 February 2008, a new immigration system was launched to ensure that only those with the right skills or the right contribution will be able to come to the United Kingdom to work and study. The points-based system enables us to control migration more effectively, tackle abuse and identify the most talented workers.
1.43 Underpinning the new immigration system is a five tier framework. This will help people understand how the system works and direct applicants to the category that is most appropriate for them. The tiers are:
1.44 One effect of the tremendous contribution, which doctors from outside Europe have made to the NHS over its sixty-year history, has been to establish an exchange of expertise and experience between the UK and other parts of the world. It is the aim of the Department of Health to support action to reinforce their continuation. Expanding the existing Medical Training Initiative, streamlined under the new immigration rules, would be one way to achieve this, amongst other benefits.
CHECKS ON THE CREDENTIALS OF DOCTORS—THE ROLE OF THE GMC
2.1 There are three levels of checks on the credentials of doctors entering the United Kingdom seeking to work in out of hours services.
2.2 The following section deals with the checks on the credentials of doctors which are undertaken at a national level.
THE ROLE OF THE REGULATORY BODY
2.3 There are currently two bodies involved in the process of setting and maintaining standards for medical education and training at a national level and which act as the UK competent authorities for certain purposes under Directive 2005/35/EC—the General Medical Council (GMC) and the Postgraduate Medical Education and Training Board (PMETB). Further details are attached at Annex A.
2.4 The GMC is the professional regulatory body for doctors and it has responsibility for administering the Register of Medical Practitioners which lists all the persons recognised in the UK as holding qualifications entitling them to practice as a medical doctor.
2.5 Following approval of the General Specialist Medical Practice (Education, Training and Qualifications) Order 2010 by the Privy Council on 10 February 2010, the functions of the PMETB are due to be transferred to the GMC on 1 April 2010.
REGISTRATION WITH THE GMC
2.6 All doctors practising in the UK, either in the NHS, or in private practice, are required to be included on the GMC's register of medical practitioners and to hold a licence to practise. They are also bound to abide by the professional standards set by the GMC.
2.7 Full Registration with the GMC indicates that a person is a qualified medical practitioner, but it does not mean that they are necessarily qualified, or competent, to undertake any given, specific role.
2.8 The GMC requires migrants from both the EEA and outside the EEA to provide proof of their identity and qualifications. It also requires proof that their fitness to practise is not impaired: this takes the form of a certificate from the host competent authority confirming that they are of good standing.
International Medical Graduates
2.9 International Medical Graduates applying for full registration must hold an acceptable primary medical qualification and will be required to submit evidence that they have satisfactorily completed either Foundation Year (F1) training in the UK or a period of clinical experience that provides an acceptable foundation for future practice as a fully registered medical practitioner.
2.10 In addition, they will be required to demonstrate their medical knowledge and skills in one of the following ways:
2.11 All International Medical Graduates who apply for either provisional or full registration with a licence to practise must satisfy the GMC that they have the necessary knowledge of English. They are accordingly required to obtain satisfactory scores in each of the four academic modules (speaking, listening, writing and reading) of the International English Language Testing System (IELTS) test administered by the British Council.
2.12 In certain circumstances a select group of bodies approved by the GMC, including the Medical Royal Colleges, may act as sponsor for an applicant's GMC registration and licensing as an alternative to taking the PLAB assessment. In these circumstances the Medical Royal Colleges (or other sponsoring bodies) provide professional sponsorship of candidates to the GMC, and facilitate a non-PLAB route to GMC registration. In these cases the sponsor takes responsibility for attesting to the level of competence of the individual.
THE PROFESSIONAL LINGUISTIC ASSESSMENT BOARD (PLAB) TESTING SYSTEM
2.13 The PLAB test is the main route by which International Medical Graduates demonstrate that they have the necessary skills and knowledge to practise medicine in the UK (except in certain circumstances, for example where they already hold an approved specialist or GP qualification). Doctors need to undertake a PLAB test if they are the national of a country outside the UK, European Economic Area (EEA) or Switzerland who graduated from a medical school outside the UK and in certain other circumstances.
2.14 The test is in two parts:
2.15 The PLAB test is designed to test a doctor's ability to practise medicine safely in a UK hospital. It is set at the level expected at the end of Foundation Year 1 (F1). This means that doctors must show that they are capable of applying knowledge to the care of patients at the level expected of a doctor who has had one year of clinical experience following graduation.
GP registration
2.16 The GP Register is a register of doctors who are eligible to work in general practice in the health service in the UK. From 1 April 2006, all doctors working in general practice in the health service in the UK, other than doctors in training such as GP Registrars, are required to be on the GP Register. This requirement extends to locums.
2.17 The GP Register was introduced alongside the changes to the system for postgraduate medical education and training under The General and Specialist Medical Practice (Education, Training and Qualifications) Order 2003.
2.18 Being included on the GP Register is one requirement for entry to a medical performers list for GPs, although this does not apply to doctors in training, such as GP Registrars. When a doctor applies to join a performers list, the PCT should contact the GMC to check whether that doctor is on the GP Register, and make other checks.
EEA DOCTORS
2.19 Doctors applying for inclusion on the register of medical practitioners from the EEA must hold a recognised qualification, listed in the Directive and issued by an EEA competent authority.[16]
2.20 Identity checks are undertaken and character references are sought from the host competent authority, but there is no requirement on EEA nationals to undergo a PLAB test, or to satisfy the GMC about their level of knowledge of English.
2.21 EEA doctors restored to the Register after prolonged absence from UK practice are advised by the GMC to work initially in an approved practice setting.
The Medical Act 1983 and Directive 2005/36/EC on the Recognition of Professional Qualifications
2.22 The Medical Act 1983 gives effect, inter alia, to the UK's obligations in European law. These are currently set out in Directive 2005/35/EC, (whose introduction and policy intent are described in paragraphs 2.26 to 2.35, below). Previous EU legislation provided for mutual recognition of numerous professions and trades in a series of instruments, but the 2005 Directive brought the procedures and requirements for most occupations together, and covers the clinical professions, including medical practitioners.
2.23 When the Medical Act 1983 was passed, its registration provisions reflected the automatic recognition provisions applying in relation to Member State nationals. Nationals of Member States with primary European qualifications listed in the European legislation, and set out in Schedule 2 to the Act, were registered on equal footing with UK qualified doctors. Later, after Directive 2005/36/EC was made the same principles were implemented by an amending order which updated[17] the Medical Act to give effect to the new Directive (see paragraph 2.28 and its footnote, below).
2.24 In terms of the wider EU obligations which the Medical Act 1983 reflects, the current Directive and its predecessor EU instruments derive from the principles of freedom of movement of persons, services and freedom of establishment in the Treaties which serve as the basis for the European Union.
2.25 Articles 49 and 56 of what is now the Treaty on the Functioning of the European Union deal with free movement between EU Member States. Those Articles provide that restrictions on the freedom of establishment of EU nationals in another Member State, or restrictions on the freedom to provide services in another Member State, are prohibited. For nationals of the Member States, this includes, in particular, the right to pursue a profession, in an employed or self-employed capacity, in a Member State other than the one in which they have obtained their professional qualification. Article 45 relates to freedom of movement of workers.
2.26 The proposal for the current Directive on the recognition of professional qualifications was introduced at the Barcelona Summit in March 2002 and presented to the Internal Market Consumer and Tourism Council on 21 May 2002. The Commission presented the draft legal text to Member States on 4 June 2002.
2.27 Consultation on the draft Directive was launched in the UK on 1 July 2002 and closed on 30 September 2002.
2.28 European Directive 2005/36/EC replaced Council Directive 93/16/EEC (free movement of doctors and the mutual recognition of their diplomas, certificates and other evidence of formal qualifications). The new Directive was formally adopted on 7 September 2005 and all Member States were required to transpose it into domestic law by October 2007. The requirements of the Directive as it applies to doctors have been transposed into UK legislation principally through amendments to the Medical Act 1983.[18]
2.29 The intention behind the Directive is to make it easier for qualified professionals (architects, accountants, teachers, health professionals, etc) to practise their professions in European countries other than their own, with a minimum of red tape but with due safeguards for public health and safety and consumer protection. It provides for the mutual recognition of diplomas, certificates and other evidence of formal qualifications in order to assist the free movement of professionals throughout the EU.
2.30 The Directive achieves facilitation of free movement of (effectively) EEA nationals[19] through the competent authorities (regulatory bodies including, in the case of doctors, the General Medical Council (GMC) for the UK). In relation to doctors, the Directive requires all competent authorities to recognise qualifications from other States if they meet the minimum conditions set out in the Directive.[20] The GMC must accept a migrant's qualifications if they meet this minimum standard. This is known as "automatic recognition".
2.31 This also applies to other EEA competent authorities where UK nationals seek to register in another EEA State.
2.32 In order for qualifications to receive automatic recognition under the Directive basic medical training must comprise a total of at least six years of study or 5,500 hours of theoretical and practical training provided by, or under the supervision of a university.
2.33 Basic medical training must provide an assurance that the person has acquired the following:
2.34 While the subject matter of medical education is often is perceived to be similar in Europe, the context and conditions in which the programmes operate are very diverse.[21] Objective qualitative assessments of the relative merits of different training systems are therefore difficult to make and the Department has no information available to it to enable a qualitative comparison to be made between UK postgraduate training and postgraduate training elsewhere in Europe.
2.35 The Directive only imposes a requirement on Member States' competent authorities to recognise professional qualifications: it does not confer an automatic right to be employed. This requirement therefore does not absolve employers of the responsibility to ensure individual professionals are fit and suitable for the appropriate job.
Numbers of EEA Migrants Registering with the GMC
2.36 Data provided to the Department of Health by the General Medical Council for the purposes of monitoring the implementation of Directive 2005/36/EC shows that in 2008 there were 2,097 migrants registered by the General Medical Council (GMC) under the automatic recognition procedure and 106 applications were accepted under the General System regime without the need for a compensatory measure. Two applications were rejected under automatic recognition, while there remained 335 applications under consideration.
2.37 In 2008 almost 1300 applications came from Germany, Greece, Hungary, Italy, Poland and Romania. In 2008 the GMC updated their management information system and unfortunately data cannot now, without intensive interventions, be retrieved from that database. The only data available for 2007 is that there were 2,510 applications for mutual recognition from EEA applicants of which 2,140 registrations were granted. The difference may be attributed to withdrawals and perhaps open applications that did not conclude until 2008.
2.38 Data for 2009 shows that there was an increase in numbers of EEA migrants obtaining registration with the GMC. 2,291 migrants (an increase of around 9% on 2008) were registered under the automatic recognition procedure and 162 registered under the General System. One application from Hungary was rejected. The bulk of the applicants came from Italy (340),. Greece (254), Romania (252), Germany (202), Poland (198) Hungary (169) and Bulgaria (142).
2.39 A small number of migrant doctors have taken advantage of the provision concerning temporary provision of services. In 2008 the number of doctors registered for temporary provision amounted to 38. The bulk of these applications came from migrants holding French and Belgian nationality (there were 10 applications from each country). In 2009, the numbers of migrant doctors registering under temporary provision of services increased from 38 to 46 with migrants holding French and Belgian nationality each totalling 11.
Exchange of Information Between Competent Authorities
2.40 There are already requirements on EU competent authorities to exchange information with each other under Directive 2005/36/EC, both when a health professional seeks to register in a new Member State and at other times.
2.41 The European Commission's Code of Conduct makes it clear that migrants from the EEA can be asked for various documents, including evidence attesting that the migrant is of good character as part of the registration process. The GMC seeks evidence that a doctor is of good character from the competent authority in the host Member State.
2.42 To enable effective communication between competent authorities, the European Commission has set up a secure web based system known as the Internal Market Information System (IMI system). The IMI system is designed to provide Member States with the tools required for them to cooperate with each other in order to improve the implementation of Internal Market legislation. The fundamental objective of the IMI system is to create the conditions in which day-to-day administrative cooperation between the Member States can take place.
2.43 The system is an enabling mechanism. It provides Member State administrations with a multilingual, open and flexible tool to support the mutual assistance and information exchange required to implement Internal Market legislation efficiently. The IMI system, which is operated and maintained by the Commission can translate specific questions in to other languages and can help track that requests for information have been answered.
2.44 The GMC has advised us that the IMI system is a useful vehicle for the exchange of information, and the Government would like to see the system strengthened in a number of ways in future:
Language Knowledge Assessment
2.45 The Medical Act 1983 provided for registration without reference to language knowledge. Following the recommendations made by the Chief Medical Officer in Good doctors, safer patients[22] and the Government White Paper Trust, Assurance and Safety[23] the Department has explored whether there is scope to reintroduce a form of language testing. We have concluded that the most effective and proportionate approach remains the focussing of checks at the point at which the migrant was taking up work.
2.46 Article 53 of Directive 2005/36/EC deals with the issue of language knowledge:
2.47 The Directive makes it clear that persons benefiting from the recognition of professional qualifications shall have a knowledge of languages necessary for practising the profession in the host Member State. However, lack of language knowledge is not a ground for refusing recognition of the qualifications of a national of another Member State—the Commission's own guidance is clear about this.
2.48 Registration with the GMC is about the recognition of a doctor's qualifications and their right to refer to themselves as a registered medical practitioner. Language knowledge, while essential for providing good patient care, is separate from ability to practice medicine and systematic language testing by the competent authority is therefore not permitted as a check on the recognition of qualifications. However, language knowledge can be checked and tested after registration with a regulatory body, eg, by a prospective employer. Any language testing after registration would have to be proportionate and appropriate for the post's requirements.
2.49 The grasp of English required by a person practising solely in a medical research capacity may be quite different from that of a general practitioner. The Department's view therefore is that, while a national standard of language assessment is superficially quite attractive as an additional safety requirement, what is more important is that local NHS organisations take responsibility for ensuring that any person they employ or contract with has the necessary grasp of English for the role they will undertake.
2.50 To this end the NHS (Performers Lists) Regulations 2004, place a requirement on a PCT to satisfy itself that a doctor has the knowledge of English necessary to perform primary medical services in its area, before admitting a doctor to its performers list (see paragraphs 3.8 to 3.12).
2.51 The Department of Health also issued Health Service Circular 1999/137[24] in June 1999 (which replaced Personnel Memorandum (87)7). The circular made it clear to all NHS employers that they are responsible for ensuring that the staff they employ have the necessary language and communication skills needed to do their job safely and effectively.
2.52 A doctor who was a national of an EEA state and holding a qualification from an EEA competent authority which was listed in the Directive would be automatically registered by the GMC, subject to providing the necessary certificate of good standing and proof of identity. However, when the doctor applied for inclusion in a PCT's performers list he or she would have to produce evidence of appropriate language knowledge. If the doctor sought employment with an NHS body, in accordance with the circular's guidance to NHS employers, the doctor would also be expected to produce evidence of appropriate language knowledge to prospective employers.
ENFORCING PROFESSIONAL STANDARDS
2.53 Once a migrant is registered with the GMC, that migrant's continued registration is subject to the normal rules and procedures set out by the GMC. The GMC would be expected to investigate if any concerns were raised with it about the fitness to practise of that doctor. Language competency can be considered as a fitness to practise issue by the GMC.
Overseas Doctors and the GMC's Fitness to Practise Procedures
2.54 Overseas doctors have historically been disproportionately represented in the numbers of doctors appearing before the GMC's fitness to practise panels. The GMC has commissioned research into this issue from both the Policy Studies Institute and York Health Economics Consortium. The GMC's research showed that some, but not all, of the difference in outcomes was explained by reference to the nature of the source of the complaint.[25]
2.55 5,195 doctors were the subject of an Enquiry by the GMC in 2008.[26] The GMC defines an enquiry is defined as information received (from a single source) that may raise concerns about one or more doctors' fitness to practise.
2.56 Of all concerns raised with the GMC, 26.9% related to enquiries about International Medical Graduates and 8.8% to doctors who qualified in other EEA states (ie other than the UK). These proportions were slightly higher than the proportions of International Medical Graduates and EEA qualified doctors in the medical workforce in England.
2.57 However enquiries were more likely to originate from `persons acting in a public capacity' (ie on behalf of a public organisation) rather than members of the public. 27% of all enquiries relating to International Medical Graduates and 25% of enquiries relating to EEA qualified doctors were raised by person acting in a public capacity. This compared with only 13% of complaints about a UK qualified doctor which were raised by a person acting in a public capacity. The majority of Enquiries from this source come from NHS Bodies or police forces.
2.58 Overseas doctors were proportionately more likely to be referred to a fitness to practise panel after investigation by a case examiner than UK qualified doctors. Of all the 1,297 cases which were passed to a GMC case examiner, 359 (27.7%) were referred for a full hearing. 147 International Medical Graduates (31.8%) and 42 EEA doctors (33.1%) were referred for a full hearing, compared with 169 UK qualified doctors (24.2%).
2.59 Of the 204 fitness to practise hearings which concluded in 2008 a disproportionate number related to cases against overseas doctors. 85 (42%) of hearings related to International Medical Graduates and 33 (16%) related to EEA doctors. Of those fitness to practise hearings which concluded in 2008 the ultimate sanction of erasure was imposed on proportionately more overseas doctors (27.1% of international medical graduates and 21.2% of EEA qualified doctors) compared with UK qualified doctors (13.1%).
2.60 The Department understands that the GMC is continuing to carry out research into this issue as it is unclear what all the factors behind the disproportionate representation of overseas doctors in fitness to practise proceedings are. It is possible that local employers or other professionals are more likely to refer overseas doctors to the GMC when there are concerns about practice.
CHECKS ON
THE CREDENTIALS
OF DOCTORS—THE
ROLE OF
LOCAL NHS BODIES
3.1 The employer of a doctor in England is ultimately
responsible for the quality of services provided by its employees
and it has a duty to ensure that any person it appoints to a post
is suitably qualified and otherwise competent to undertake the
role. Similarly, a PCT is responsible for ensuring that any person
it contracts with delivers their contractual responsibilities
to an acceptable standard.
3.2 The PCT or the employer also has an ongoing role in monitoring the quality of services provided by persons it employs, or contracts with, and it is responsible for taking any action required where concerns are raised about the performance of a person with whom it contracts or an employee.
PRACTISING AS A GP
3.3 The position with regards to general practitioners in England is more complex as many are self-employed. Therefore, the Government has introduced an intermediate tier of scrutiny over the quality of doctors entering general practice through the NHS (Performers Lists) Regulations 2004 ("Performers Lists Regulations").
3.4 Doctors cannot work in general practice providing services to NHS patients in England unless:
3.5 Under the Performers List Regulations 2004 there are a number of checks that a PCT is required by law to carry out before admitting a doctor onto its list. The Regulations include a requirement at regulation 6(2)(b) that a Primary Care Trust must refuse to include a performer in its performers list where:
3.6 Where a PCT refuses to admit a doctor to its Performers List it must notify the General Medical Council. Equally, where a PCT has (or is made aware of) concerns that a doctor's ability to perform his duties as a medical practitioner may be impaired they should consider the need to make a referral to the General Medical Council.
3.7 Where a GP is also an employee, it is up to employers to satisfy themselves that the person will be able to communicate effectively with patients and colleagues.
The Performers List System
3.8 Following criticisms about the way the NHS handled concerns around healthcare professionals' suitability, efficiency and probity in the primary care setting, the modern list system was developed from 2001. Its current form was established in the Performers List Regulations 2004 (as amended). The Performers List Regulations provide a framework which enables PCTs to assure the suitability of all general practice doctors, dentists and optometrists who undertake clinical services in their area through admission, conditions, suspension and removal procedures. The Regulations provide a framework to protect patients from unsuitable or inefficient practitioners.
3.9 In the White Paper Trust, Assurance and Safety the Government announced that it would be reviewing the Performers List arrangements in England to consider whether they were being used effectively.
3.10 In May 2007, the Department issued a call for ideas inviting comments on the future shape of the performers list system. It also established a Working group under the Tackling Concerns Locally Workstream to take the review forward and to publish a report that would contain recommendations for change.
3.11 The review, published in March 2009[27] reiterated the importance of the safeguards provided by the performers list system and recommended that it should be retained for doctors, dentists and optometrists. However, the report acknowledged that there was room for improvement and it made 64 recommendations covering: admission to the list; maintaining and updating the list; suspension and removal from the list; sessional and locum staff; building capacity in PCTs; and the remediation, reskilling and rehabilitation of health professionals.
3.12 Detailed work on the implementation of the recommendations has begun. The Department expects to undertake a public consultation on revised performers list regulations and guidance in summer 2010. The revised regulations are expected to be placed before Parliament at the end of the year.
THE NHS PRE AND POST APPOINTMENT CHECKS DIRECTIONS 2002
3.13 The NHS Pre and Post Appointment Checks Directions 2002 came into force in England on 1 July 2002. The Directions were introduced following a commitment given by Sir Nigel Crisp in his capacity as Accounting Officer to the NHS at the Public Accounts Committee hearing on 14th January 2002 concerning the use and availability of references.
3.14 The Directions, which confer a legal obligation on NHS bodies, require them to undertake a number of pre-employment checks and enquiries on persons they intend to appoint. The Directions include (amongst other things) a requirement to:
3.15 If pre-appointment checks are delegated to an agency or some other body, then NHS bodies must satisfy themselves those checks are carried out.
INDUCTION.
3.16 Induction is not intended to provide a "check" on the credentials of a doctor, but it is important that an adequate induction into a new role is provided and patient safety may be compromised if the basic information that a doctor needs to do their job is not provided to them by their employer.
3.17 Employing organisations have an obligation to ensure that any services they provide are safe and they owe a general duty of care to both their employees and to patients. It is therefore for employers to provide a relevant induction. The content of induction needs to be role specific and reflect the local circumstances in which the doctor will be working.
3.18 The recent review of the Performers List system undertaken by the Department of Health (England) contains the following recommendation:
3.19 This recommendation will be taken forward as part of the implementation of the Performers List review.
3.20 It is also a term of a GMS Contract that arrangements are in place for training and maintaining skills and knowledge, as well as conditions for employment and engagement (see paragraph 53 to 62 of Schedule 6 to the GMS Regulations). Similar mirror requirements apply in respect of PMS Agreements, APMS contracts and requirements where a PCT is providing services themselves.
Postgraduate Deanery Assessment and Induction Programmes
3.21 The Royal College of General Practitioners has issued advice to primary care organisations to the effect that if they cannot be certain that an applicant for a performers list meets all the following criteria, patient safety could be compromised and further information on the applicant should be sought:.
3.22 The RCGP advises that compliance with these criteria should be assessed by the local postgraduate deanery, though decisions under the Performers List Regulations must always be taken by PCTs (who are legally responsible and accountable for such decisions). Deaneries are however experienced in making assessments of educational need and, resources permitting, can provide tailored assessment and induction programmes to help PCTs meet their statutory functions.
ROLE OF NHS BODIES IN MONITORING THE FITNESS TO PRACTISE OF DOCTORS AND ADDRESSING CONCERNS
3.23 Once doctors are working for an NHS Employer, or as a contractor to a PCT, the NHS body is responsible for the quality of services provided by its staff/contractors. As part of their responsibilities NHS organisations are expected to ensure that any complaints or concerns are acted on and that clinical governance systems are maintained. Good clinical governance is particularly important as it provides a means for detecting concerns before a serious incident occurs.
Clinical Governance
3.24 Clinical governance is a framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. This framework includes a number of specific processes and structures that are more generally focussed on organisational culture change.
3.25 This framework includes the following clinical governance processes:
3.26 The concept of clinical governance was first described in The new NHS: modern, dependable.[28]
3.27 The Department published "Clinical governance reporting processes" in November 2002.[29] This clearly sets out the expectation that all NHS Trusts have responsibility for ensuring that clinical governance principles, processes and systems are reformed.
3.28 In Safeguarding patients,[30] the government accepted that, despite progress in implementing the structures and processes of clinical governance, further work was needed, in particular to achieve the cultural change which the structures and processes of clinical governance are intended to promote.
3.29 In March 2009, the Department of Health published reports produced by the Tackling Concerns Locally working group.[31] The group included a wide range of stakeholders with considerable expertise in this area. The reports set out principles of best practice and make recommendations to the Department and the NHS regarding how local systems of clinical governance could be strengthened to promote continuous improvement in the quality of care and enable healthcare organisations to identify and deal with those healthcare professionals whose performance, conduct or health could put patients at risk.
3.30 Current developments in clinical governance focus on strengthening local arrangements for clinical governance and reforming the national arrangements for professional regulations and patient safety. This integrated approach will deliver greater benefits than a pure focus on clinical governance alone.
Appraisal
3.31 An annual appraisal is a requirement for all doctors working for the NHS in England, and has been so since 2002.
3.32 Medical appraisal aims to help doctors consolidate and improve on good performance, and identify areas where further development of knowledge or skills may be required, or useful. The content of the appraisal discussion is based on the GMC's publication Good Medical Practice which describes the standards of good medical practice, and standards of competence, care, and conduct which are expected of all doctors. Doctors provide data and supporting information to their appraiser to illustrate how they are meeting the requirements of Good Medical Practice.
3.33 While appraisal is primarily intended as a mechanism to support the continuing professional development of doctors, if any serious concerns about a doctor's practice are identified during the appraisal meeting, which may affect the safety of patients, discussion is stopped, and the appraiser must urgently refer the matter to the senior clinician, and Chief Executive in the case of a PCT. If concerns are such that they call into question a doctor's fitness to practise, then they should be reported to the GMC.
3.34 It is a requirement under the GMS contract that a doctor participates in the appraisal system provided by a PCT unless he participates in an appropriate appraisal system provided by another health service body or is an armed forces GP and co-operates with an assessment by the NPSA when requested to do so by the PCT. The PCT must provide an appraisal system after consultation with the LMC for its area.[32] Similar mirror provisions exist in respect of PMS Agreements and in an APMS contract. The Performers List Regulations also require participation in the appraisal system provided by a PCT unless an armed forces GP.[33]
3.35 Although participating in appraisal is a requirement for all doctors, the implementation of appraisal is not currently of a consistent quality across England. New processes, which will be introduced as part of medical revalidation, will strengthen appraisal, and introduce a more consistent approach.
Addressing concerns
3.36 Where concerns are identified about a practitioner the employer is responsible for deciding on the most appropriate course of action to be taken. In many cases concerns will be resolved locally, either through informal action or through formal disciplinary procedures. Where there are concerns about a doctor's performance employers may seek advice from the National Clinical Assessment Service (and they must notify them where a doctor is suspended).
3.37 Where there are concerns about the fitness to practise of a doctor then the doctor should make a referral to the GMC.
REFERRAL OF OVERSEAS-QUALIFIED DOCTORS TO NCAS
3.38 Information about the extent of concerns raised about overseas doctors is held by the National Clinical Assessment Service (NCAS). Information from NCAS suggests that concerns, which result in a referral to NCAS or a suspension or exclusion, are more likely to arise in respect of the performance of International Medical Graduates and EEA doctors than UK doctors. Further details are attached at Annex B.
3.39 It remains unclear why it is the case that overseas qualified doctors are more likely to be referred to NCAS, or suspended or excluded, than UK qualified doctors.
ROLE OF CQC
3.40 The system regulator also has a role in ensuring that the relevant checks on the credentials of doctors are undertaken by NHS bodies. From 1 April 2010, subject to approval of secondary legislation, NHS providers of regulated activities in England will be required to register with the Care Quality Commission (CQC).
3.41 The draft Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 set out the requirements that providers of regulated activities must meet in order to be registered with the CQC. Regulation 21 sets out requirements relating to workers. The regulation requires providers to operate effective recruitment procedures to ensure that employees are of good character, have the necessary qualifications, skills and experience and are physically and mentally fit for the work
3.42 The provider is required to ensure that, where a CRB or enhanced CRB certificate is required under the Police Act 1997, this is available along with evidence of conduct in relevant previous employment. The provider must also ensure that documentary evidence of relevant qualifications is available along with a full employment history and, where a person has previously been employed in work involving children or vulnerable adults, satisfactory verification of why their position ended.
3.43 The CQC will inspect providers for compliance with the Regulations and if the provider is found to be in breach of the regulation, it will be able to take enforcement action.
FUTURE DEVELOPMENTS : ENHANCING PUBLIC PROTECTION
4.1 In addition to the specific measures which we have proposed to address the concerns which have been raised about a small minority of doctors working in GP out of hours services, there are a number of initiatives that the government is currently taking forward as part of the Professional Standards Programme which will, in future, strengthen the systems in place for ensuring that all doctors, including those from overseas, are fit to practise.
Revalidation
4.2 The GMC introduced a new requirement for all doctors to hold a licence to practise on 16 November 2009 and we plan to work with the GMC to introduce a new system of revalidation in the future. This will mean that all doctors will regularly have to prove to the GMC that they are up to date and fit to practise medicine.
4.3 A system of revalidation for doctors will be phased in during 2011/2012, whereby all doctors licensed by the GMC will have their licence to practice reconfirmed every five years.
4.4 Revalidation will be underpinned by a number of elements which build on what is currently best practice: a strengthened form of annual medical appraisal; feedback from colleagues and patients; and evidence of Continuous Professional Development. Doctors will build a portfolio of supporting information over five years which will be brought to their annual appraisal and which will demonstrate how they are meeting the requirements of Good Medical Practice and any specialist standards set by their Royal College.
4.5 Revalidation will provide patients with the assurance that their doctor is up to date and fit to practise, and will support doctors in developing their expertise throughout their career.
4.6 The revalidation processes are being piloted during 2010 and the first quarter of 2011 in a variety of settings. These pilots will be independently evaluated to test that the processes provide the right degree of rigour to make a revalidation recommendation to the GMC about the doctor without imposing unnecessary administrative burdens.
Responsible Officers
4.7 The Medical Act (as amended by Health and Social Care (Community Health and Standards) Act 2008) enables the role of Responsible Officers to be set out in Regulations. Draft Regulations will be laid before Parliament shortly and, subject to Parliamentary approval, Responsible Officers will be in post from 1 October 2010.
4.8 Responsible Officers will have a key role in the management of doctors and of the quality of care, they provide including ensuring that pre-employment checks are undertaken. In Primary Care, in England, Responsible Officers will also be given personal statutory responsibility for managing admission to the Performers List. Bringing the two functions together will improve the management of Performers Lists and enable issues to be identified and addressed earlier.
4.9 The role of Responsible Officers, in England, is integral to improving quality of care and ensuring a focus on the three core components of quality described in the `High quality care for all'.[34] Where concerns arise about a doctor, the Responsible Officer will have responsibility for deciding whether local processes of remediation are appropriate, or whether the concerns are serious enough to warrant a referral to the GMC on the grounds that the doctors fitness to practise may be impaired.
4.10 They will have a key role in the oversight of doctors and improving the quality of care they provide. Responsible Officers in England will be responsible for ensuring that their organisation has appropriate clinical governance systems in place to monitor the performance and conduct of doctors. Where an issue is identified, they will need to take appropriate action to ensure the safety of patients and improve the quality of care.
4.11 It is also envisaged that in future Responsible Officers may have a role in evaluating a doctor's fitness to practise and making a recommendation to the GMC regarding whether a doctor should be revalidated..
4.12 We propose to issue guidance to accompany the new Responsible Officer Regulations to make it clear that the proposed new duty on Responsible Officers to "manage admission to the performers' list in accordance with the National Health Service (Performers Lists) Regulations 2004" includes assuring themselves that the PCT has adequately discharged its duty to assess language knowledge.
4.13 The draft regulations were consulted on between August and October 2009 and are due to be made later this year. In effect, the proposed new duty would provide a clear point of accountability for ensuring that the necessary checks have been undertaken.
Duty of Cooperation Regulations
4.14 New regulations setting out a duty to share information between prescribed bodies, are expected to be consulted on in early 2010. The proposed new regulations will require a designated body (in England and Wales) to share information about a healthcare worker's conduct or performance which may show that there may be a threat to patient safety. These regulations will be aimed at fostering greater cooperation between a range of bodies, particularly the employers of healthcare workers and the national regulators.
1 March 2010
1. This Annex summarises the functions of the two bodies involved in setting standards for postgraduate medical education and training—the General Medical Council (GMC) and the Postgraduate Medical Education and Training Board (PMETB).
GENERAL MEDICAL COUNCIL
2. The General Medical Council (GMC) is the independent regulator for doctors in the UK. It was established under the Medical Act of 1858 and its function is to protect patients and the public from poorly performing doctors.
3. The Medical Act 1983 sets out the current legislative basis for the GMC. The GMC's main statutory objective is to protect, promote and maintain the health and safety of the public. The Medical Act 1983 gives the GMC four main functions:
4. The GMC has strong and effective legal powers designed to maintain the standards the public have a right to expect of doctors. Where any doctor fails to meet those standards, it acts to protect patients from harm—if necessary, by removing the doctor from the register and removing their licence to practise medicine.
5. The GMC is independent of control by Government, the employers of doctors and the profession it regulates. It is accountable to Parliament, through the Privy Council for the discharge of its statutory functions. The Government and the GMC work together to deliver certain policies, however—eg, licensing and revalidation of medical practitioners.
6. The GMC is a registered charity in England and Wales and Scotland. Its governing body, the Council, has 24 members of which 12 are doctors and 12 are lay members, all appointed by the Appointments Commission.
THE POSTGRADUATE MEDICAL EDUCATION AND TRAINING BOARD
7. The Postgraduate Medical Education and Training Board (PMETB) is an independent statutory body responsible for overseeing and promoting the development of postgraduate medical education and training for all specialties, including general practice, across the UK.
8. The PMETB assumed its statutory powers on 30 September 2005, taking over the responsibilities of its two predecessor bodies the Specialist Training Authority of the Medical Royal Colleges and the Joint Committee on Postgraduate Training in General Practice. Its statutory responsibilities include establishing, promoting, developing and maintaining standards and requirements for postgraduate medical education and training across the UK.
9. PMETB's functions include awarding Certificates of Completion of Training (CCT) and determining the eligibility of doctors for inclusion on the Specialist and GP Registers.
10. Unlike the Specialist Training Authority, which was a body of the medical Royal Colleges, PMETB was created by statute and is independent of the medical Royal Colleges. Although PMETB works closely with the medical Royal Colleges, relationships are governed by PMETB commissioning services from the medical Royal Colleges
MERGER OF PMETB WITH THE GMC
11. From 1 April 2010 the functions of the PMETB will be transferred to the General Medical Council and the PMETB itself will be abolished.
12. Following the merger the GMC will take over responsibility for approving standards for postgraduate medical education and training, for awarding Certificates of Completion of Training (CCTs) and for determining the eligibility of doctors for inclusion on the Specialist and GP Registers.
13. The merger will enable a common approach to both undergraduate and postgraduate education and training to develop, and facilitate sharing of expertise, which will in time improve efficiency in processes which themselves support the continued improvement of medical practice and more importantly, in patient care. The merger will also create a single competent authority for medical education and training and a single point of contact for doctors, employers and other partner organisations.
1. NCAS is a division of the National Patient Safety Agency. Where there are concerns about the performance of doctors NCAS can be asked to advise.
2. A range of services is offered including formal assessment. Over 700 referrals of doctors are made each year, from all parts of the UK and surrounding jurisdictions. NCAS also advises on the performance of dentists and pharmacists.
DATA HELD BY NCAS
3. NCAS was set up in 2001 and has collected demographic data about its cases since starting operations. Cases are classified using standard NHS groupings so that comparisons with the NHS medical workforce can be made. This can identify doctor groups where referrals may be occurring relatively more or less frequently.
4. Care must be taken in interpreting these
comparisons because groups of practitioners can vary in many ways
and a referral association with one doctor characteristic may
actually be reflecting associations with other characteristics
outside the immediate comparison—age or gender or grade
differences, for example. NCAS therefore used regression methods
as well as descriptive comparisons, to establish whether associations
are statistically significant. This work was published in `NCAS
Casework: The First Eight Years'[35]
in 2009.
5. NCAS Casework: The First Eight Years
also examined use of suspension and exclusion from work, as a
subset of NCAS referrals. The report's detailed comparisons with
the NHS workforce were confined to England because it is difficult
to assemble fully consistent workforce comparator data covering
the whole of the UK.
6. NCAS recording of place of qualification distinguishes the UK from other EEA countries and countries outside the EEA. Over eight years 2001/02-2008/09, 4264 doctors were referred to NCAS. Place of first qualification was recorded for 79% of them. For suspension or exclusion cases (included in the 4264) place of first qualification was recorded in 90%. NCAS data are therefore reasonably complete. 3828 referrals of the 4264 came from England.
7. In "NCAS Casework: The First Eight Years" comparisons of doctors by place of qualification were limited to UK and "the rest" because only 367 practitioners were identified as qualifying in the EEA. Further analysis is planned as more referrals are made.
FINDINGS
8. The following findings were reported by NCAS based on a comparison using three place-of-qualification groups.
9. Tables 1 and 2 use NCAS Casework: The First Eight Years datasets to expand on these conclusions by distinguishing EEA-qualified doctors from other doctors qualifying outside the UK. "Not knowns" are assumed to be randomly-distributed amongst the three place of qualification groups. Only England cases are included to aid comparison with the workforce.
Place of first qualification | Number of referrals GP
H&C | All | Per cent of referrals* GP | |||
| H&C | All | |||||
UK | 553 | 964 | 1,517 | 51 | 50 | 50 |
| Other EEA | 88 | 163 | 251 | 8 | 8 | 8 |
| Outside EEA | 439 | 811 | 1,250 | 41 | 42 | 41 |
| Not known | 318 | 492 | 810 | |||
| 1,398 | 2,430 | 3,828 | 100 | 100 | 100 | |
|
*Note that percentages may not add up to 100% because of rounding | ||||||
Place of first qualification | Number of suspensions/ exclusions GP
H&C | All | Per cent of suspensions/ exclusions* GP | |||
| H&C | All | |||||
UK | 84 | 125 | 209 | 41 | 40 | 41 |
| Other EEA | 17 | 24 | 41 | 8 | 8 | 8 |
| Outside EEA | 103 | 163 | 266 | 50 | 52 | 52 |
| Not known | 23 | 28 | 51 | |||
| 227 | 340 | 567 | 100 | 100 | 100 | |
|
*Note that percentages may not add up to 100% because of rounding | ||||||
10. Table 3 shows the place of qualification profile of the GP and Hospital and Community doctor workforce in England in 2008 and table 4 compares the workforce profile with the profiles of exclusions and suspensions in tables 1 and 2:
Place of first qualification | England medical workforce, September 2008 | Per cent of workforce* | ||||
| GP | H&C | All | GP | H&C | All | |
UK | 26648 | 59719 | 86367 | 78 | 63 | 67 |
| Other EEA | 1619 | 5956 | 7575 | 5 | 6 | 6 |
| Outside EEA | 5743 | 28807 | 34550 | 17 | 30 | 27 |
| 34010 | 94482 | 128492 | 100 | 100 | 100 | |
*Note that percentages may not add up to 100% because of rounding. Note that GP figures exclude GP retainers and registrars | ||||||
| General practice, per cent | H&C doctors, per cent | |||||
| Place of first qualification | Referrals over 8 years to 2008-09 | Suspensions to end of 2007-08 | Workforce, September, 2008 | Referrals over 8 years to 2008-09 | Exclusions to end of 2007-08 | Workforce, September 2008 |
| UK | 51 | 41 | 78 | 50 | 40 | 63 |
| Other EEA | 8 | 8 | 5 | 8 | 8 | 6 |
| Outside EEA | 41 | 50 | 17 | 42 | 52 | 30 |
| 100 | 100 | 100 | 100 | 100 | 100 | |
11. Table 4 suggests that both groups qualifying outside
the UK are over-represented amongst referrals and suspensions/exclusions.
The comparison is not perfect because NCAS data relate to an eight
year period so use of a mid-period workforce profile would be
more accurate. Since the non-UK-qualified workforce is growing,
relatively, this would strengthen a conclusion that doctors qualifying
outside the UK are over-represented in referrals to NCAS and in
suspensions and exclusions reported to NCAS.
12. NCAS Casework: The First Eight Years comparisons
therefore also looked at associations with ethnicity, which is
closely associated with place of qualification. For the Hospital
and Community sector, NCAS Casework: The First Eight Years
conclusion was that there is an increased likelihood of performance
measures amongst non-white non-UK qualified doctors but not amongst
non-white doctors qualifying in the UK. General practice lacks
workforce comparator data on ethnicity.
13. These comparisons are made by NCAS as part of an on-going equality monitoring programme.
